The physician’s role in cost containment is absent during training

After graduating from college I had the opportunity to spend two years working at the Institute of Medicine on a variety of health care improvement topics. When it came time to apply to medical school I noticed an odd dissonance—the challenges I had been grappling with at the IOM were not manifest in most medical school curricula. I knew that multidisciplinary teams deliver the best care, but I was going to learn almost exclusively alongside fellow physicians-in-training. I had learned that deficiencies in care delivery harm patients, but neither quality nor systems improvement would be areas of focus. The inattention to health care costs was particularly glaring. Rarely a day passed at the IOM where I did not attend a meeting, read an article, or work on a report that dealt with the cost crises in health care. But these challenges, and the physician role in cost containment, were absent from most school’s curricula.

I wanted to find a school that would allow me to build on my experience at the IOM, but I found it difficult to assess the extent to which schools were committed to teaching students about cost and value. Websites and curriculum catalogues quickly blend together, but I did notice that educational objectives offered an interesting glimpse of a school’s educational ethos. Unlike the standardized core competencies of residency programs, the Liaison Committee on Medical Education (LCME) allows medical schools to develop their own core educational objectives. The lack of standardization made these objectives a convenient way to gauge a schools commitment to preparing students for contemporary challenges in health care.

At the time I remember being disappointed by how few schools incorporated an understanding of health care costs and the physician role in resource stewardship into their educational objectives. Curious if these impressions were representative, I decided to take a more methodical approach and survey the educational objectives for a larger sample of medical school. What I found was unsettling. Among the top 25 research-focused medical schools, 50% include awareness of the economics and financing of health care in their educational objectives, and only 28% mention the role of physicians in cost control and resource stewardship. The picture is similar for the top 25 primary care-focused medical schools, where the results are 50% and 25%, respectively.

Acknowledging these deficiencies, leaders have recently called for better education on cost and value across the training continuum, particularly in residency training and the clinical years of medical school. But it is important to start earlier. There are two reasons this type of education should start on day one. First, it provides students with skills, knowledge, and time to grapple with the complex practical and ethical challenges of cost containment before they are in the position to make medical decisions. Students can then approach their clinical rotations with an eye towards high-value care, using practical experience on the wards to supplement and enrich a strong theoretical foundation. Second, focusing on cost and value early and often send a signal to students, and the medical community more broadly, that cost-awareness is a key competency for the modern physician. By making these issues core longitudinal themes, medical schools can build a culture of high-value care delivery among a new generation of doctors.

Resource stewardship and cost-effective care are widely endorsed as key components of physicians’ professional responsibility. As such, medical schools have an obligation to ensure that these principles are incorporated into their core educational objectives. Medical students deserve an education that will prepare them to meet the challenges of modern medicine.

The physician’s role in cost containment is absent during training 25 comments

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southerndoc1

‘Resource stewardship and cost-effective care are widely endorsed as key components of physicians’ professional responsibility’
What is my “professional responsibility” to provide cost effective care when all the savings go straight to the bottom line of for-profit insurers?
This is another blame-the-doctors talking point. If you want to reduce the cost of care, take a lead from Willie Sutton and go after big insurance, big pharma, big medical equipment, and big hospital corporations.
I didn’t cause this problem and I can’t fix it.

http://www.facebook.com/dane.gruenebaum Dane Gruenebaum

Just because you didn’t start the problem doesn’t mean you can’t help be a solution. People don’t get big pharma drugs from you unless you write for them do they really need the $300 a month combo antihypertensive so they can take 1 pill instead of 2 or will you suggest they spend $8 and get 2 of the 4 dollar generics. Investors own the insurance companies, people with retirement accounts like you and I. With the stipulations of the PPACA there is a cap that so much has to be paid out in benefits or returned to the purchaser of the policy. It’s time to stop making excuses and have candid discussions about whats really best for our patients.

southerndoc1

The problem isn’t me, it’s pharma charging $300 for the combo of two generics, and the insurers accepting that as their allowed charge.
You’re casting this as doctors versus patients, which is exactly what for-profit insurers, pharma, and hospitals want (as they laugh all the way to the bank).

http://www.facebook.com/dane.gruenebaum Dane Gruenebaum

I doubt the problem is you, I do not think any of us wants to contribute to the problem, but if you choose to write for a combo pill that cost 10x what the separate ingredients do it’s not a solution. This is a big problem with a lot of variables that aren’t always clear but running away saying the problem isn’t you is a problem. You might not think it is, you might justify what you do by saying its the “Standard of care”, or if you don’t give it to them someone else will. But it’s our profession and unless we stand up and fight for what is right with the patient and improving high value care, what’s wrong will continue unabated. Nonproviders have dictated the course of healthcare policy because for too long many of us have focused on simply providing care or other pursuits. I challenge you sir/madame be a patient advocate inside and outside the exam room and help patients make informed decisions.

John Henry

Better check again what the “generic” medication you think is so cheap is actually selling for. In my field, generics as old as Adam are selling for what could be only called staggering amounts.

grace

“The problem isn’t me, it’s pharma charging $300 for the combo of two generics, and the insurers accepting that as their allowed charge.”

But if you had a patient with no prescription coverage sitting on the other side of your desk, and you knew she sometimes had a hard time making ends meet, I expect you’d take the time to write her an individual script for each of the generics rather than write her up for the combo knowing that it’s gonna cost her a week’s rent. Because you wouldn’t want a week’s worth of her rent going to big pharma if it didn’t have to. Because when it comes down to it, I expect that you like most doctors are on your patients’ side.

So, no, the *problem* isn’t you; but in a case like the above, the *solution* can be you.

trinu

I don’t know of any physician, who writes “brand name only” on the prescription pad. I do know of insurance companies, refusing to cover a doctors prescription, because some bureaucrat thinks another drug will be “just as effective” but much cheaper. Part of the problem with saying a drug is “just as effective” is that “just as effective” in insurance company lingo often doesn’t include side effects. A racemic mixture and a drug with only the active enantiomer are usually equally effective, but the drug with only the active enantiomer often has a better side effect profile.

http://www.facebook.com/dane.gruenebaum Dane Gruenebaum

That’s not the issue that we are talking about. Yes I remember my O Chem and yes 10mg of esomeprazole is equally as efficacious as 20mg of omeprazole, while theoretically reducing side effect profile.

trinu

As I said before, I’m not aware of any physician, who puts, “brand name only” or any variation thereof, on prescriptions.

ninguem

The only time I’ve written “brand name only”, or “dispense as written”, or “brand necessary”, or any of those magic words, in the last ten years, is because patients insisted on it.

I have one patient who insists on “brand necessary” for medicines that I don’t even think have brands anymore (hydrochlorothiazide for example). Patient claims “allergy to generics”……literally.

The pharmacies just humor the patient, more often than not.

http://www.facebook.com/dane.gruenebaum Dane Gruenebaum

Thanks for the great articles it is a big misperception and unfortunately you pointed out a glaring problem with out system.

http://onhealthtech.blogspot.com Margalit Gur-Arie

I’m sorry, but I don’t quite understand the reference to “complex practical and ethical challenges of cost containment” that medical students need to be trained to “grapple” with. What exactly are we talking about here? Surely this is not concerning generic substitutions, or non-duplication of tests, or not harming patients by performing superfluous procedures…

So what is it about “[r]esource stewardship and cost-effective care” that may pose ethical challenges to a physician not versed in the art of “cost containment”?

buzzkillerjsmith

Gobbledegook. Perhaps our young med stud will be a big wheel in the ACP someday.

http://twitter.com/FerkhamPasha Ferkham pasha

I don’t believe doctors write what brand of prescription a patient should buy

grace

No, but if there is a medicine called SoooooperDoooooper, brand new and with no generic equivalents out yet, but really all it is is a tablet combining 25mg of Sooper + 25mg of Dooper; if a doctor prescribes that (and it costs $300/month), rather than one script of the generic form of 25mg Sooper ($6/month) and one script of the generic form of 25mg Dooper ($5/month)… that’s wasting either the patient’s (if they’re self-pay) or the insurance company’s (if they’re insured) or the government’s (if they’re Medicare/Tricare/Medicaid) money. Yes?

ninguem

“…..I don’t believe doctors write what brand of prescription a patient should buy…..”

Well…….we CAN insist on brand-name drug, but it’s rare to do so…..at least in my practice, I won’t speak for others. Sometimes we have no choice, there is no generic equivalent. My only “brand necessary” prescriptions is because the particular patient insists. Fine, patient just pays more for the branded drug, patient thinks it’s money well spent. It’s a free country.

buzzkillersmith

Ah, to be a young, idealistic physician-to-be. It’s da money, young guy. If physicians will earn a lot more money by causing a lot more money to be spent, they will do so. Wake up an econ grad student at the local pub and he’ll tell you the same thing.

Nah. You don’t need to start much in med school. Sure, a lecture or 2 or a touchy-feely seminar in years 1 and 2 won’t do much harm. Maybe having the IM or FM attending furrow his brow, shake his finger, and say that we should all save money. Do it a little in years 3 and 4. Won’t hurt probably.

Cost-effectiveness is hugely important and should be emphasized–in residency. It was in my FM residency and that was in the 1980s. Look, the only real way to save much money is to keep as many pts as possible in primary care and out of the hospital and the only way to do that is to pay primary care doc much, much more to do that so as to markedly increase the supply of such docs. As regards the procedural subspecialists-well, if the pt gets to them, the checkbook is wide open anyway. Same with the hospital.

I think something like 30 more American med students chose FM this year compared with last year. Lots more IM but they say 80% of them will subspecialize .Good luck saving money with all that!

morebuzzkills

buzzkillersmith, what excellent points you raise! I frequently stalk the posts on kevinmd and thoroughly enjoy the comments. As a rule, I do not comment…but I can’t resist because you touch on so many important points. As a current medical student, I am SO GLAD that you realize the potential dangers of constantly identifying the time of early physician training as opportunities to improve the deficiencies of the current health care system. While I agree with the author of this post that this can appear very attractive for addressing some of the deficiencies of US health care, it is not without its own caveats. I attend a school that has taken this bait hook, line, and sinker. At the end of my first two years, I felt like I had received more of an education in philosophy and public health than I had in basic medical sciences. As disappointed as I was about this, I would hazard to guess that the administrators would actually be pleased about this because I had “awareness” and “empathy” for the broader issues that plague our health care system. Never mind that I didn’t have a sound understanding of basic pathophysiology of disease and treatments…those would be “picked up” as I moved through my clinical years. The point that I would like to raise is this: “picking up” disease processes and treatments is inherently dangerous. Make no mistake, I can memorize incredible amounts of information…but do I truly understand this information? As I studied for USMLE Step 1, I found out that the answer to this was a resounding “no.” The question I had to ask myself was, “What would patients actually prefer: A physician who has a solid understanding of their disease process and ways to treat it or a physician who is aware and empathetic to broader issues in health care?” The answer was obvious; ideally they would have a physician who had all of these qualities. But, therein lay the problem: I was forced to sacrifice a deep understanding of the disease process and its treatments for becoming aware and empathetic to broader issues. I then had to ask myself, if patients were truly seeking these softer qualities in physicians (and not the solid scientific understanding of disease and treatment), why wouldn’t they just go to a sociologist or a public health professional? Make no mistake, these qualities are also paramount to being a successful physician, but is their ideal place in undergraduate medical education? In other words, should the basic sciences be sacrificed in any way for these softer issues?

This segues to my next point: the above story is nothing more than the tragedy of misguided incentives. This is a story that echoes across so many societal issues, but it is rarely ever heard. Consider the situation of undergraduate medical education (i.e. the first two years that used to be known as the “basic sciences”). The National Board of Medical Examiners considers the basic sciences to be very important as evidenced by the content on the USMLE Step 1 exam. My school states that this exam is important, but so are many other aspects that go into medical education. Consequently, there was less emphasis on teaching the basic sciences and more emphasis on topics that fostered qualities outside the direct scope of basic disease and treatment. Administrators then scratched their heads when they started surveying students at the end of the second and fourth years and found that the majority of students were already “burnt out” and that their values had changed significantly from when they had first entered medical school. As a personal aside, many older attendings have shared with me that they find medical students and residents much less capable and prepared than they were 20 years ago. Is the reduced focus on basic sciences partly responsible for this? I don’t know…but I can’t help but suspect that is at least playing a part. But I digress…back to the incentives. In the first two years, most students know that residency directors use the Step 1 score to sort applicants. Not surprisingly, most students feel that this is a fundamentally important part of their undergraduate educations. I know that there are certain people out there who will say otherwise and I acknowledge that there are exceptions to this rule. However, if you take into account the preponderance of Step 1 test preparation companies and the sheer number of internet forum posts about the topic, its importance cannot be understated for the overwhelming majority of medical students. Accrediting bodies must also feel that this exam (and the content it represents) because we still have to take it after all. So how do incentives play into this? The overwhelming majority of students have a direct incentive to do as well on this exam as they possibly can so that they can maximize their competitiveness for residency since most programs stratify applicants by Step 1 scores. Like it or not, anything in the first two years of school that crowds out the Step 1 content is either a direct or indirect disincentive to most students. This fosters burnout, frustration, and sometimes confusion among students and often leaves administrators scratching their heads. Restructuring anything in the first two years of medical education requires consideration of the Step 1 incentive. The incentive can be mitigated either by residency programs or accrediting bodies (or both) banishing the numerical score of the exam, it can be acknowledged by schools and students’ mastery of the content can be facilitated (which is the test’s original goal if my understanding is correct), or it can be minimized by schools which creates a clash of incentives. The latter leaves students feeling unsupported by their curriculum and school administrators wondering why there is so much resentment to “innovative” new classes and learning models.

How do incentives play into the author’s original argument and buzzkillersmith’s responses? As buzzkillersmith points out, if physicians earn more money by causing more money to be spent, they will do so! It is simple, if you tell factory workers that they are going to be paid by the number of products they produce, they will produce more products! Of course this is on a macro level, there will always be physicians who “do the right thing” and try to rein in costs…but they will be a distinct minority. This is evidenced by the current situation of health care costs: nearly all of physicians are aware of the fact that health care costs are out of control, but they continue to order/perform/whatever because that is a) how they make money and b) how they protect themselves against litigation. What is the point of all my banter? You can put as much cost and value education as you want into medical training, but it is not going to do a darn thing on the macro level until the financial incentive for physicians is changed. In fact, it might even breed resentment and bitterness among some physicians. Let’s return to our factor worker example for a moment, imagine that the foreman tells the factory worker to reduce the number of products that he produces in a day…even though he will still be paid by the number of products he produces! Do you think the factory will comply? Perhaps he will, if he is an idealist. But let’s now imagine that our factory worker has three children, a mortgage, and wants to provide college educations for his kids. Not enough? Let’s go a step further: now imagine that the factory worker spent 14 years training with no compensation for his job in the factory and accrued over $200,000 of debt in the process. Catch my drift?

Finally, I implore the readers of this blog not to fall into the trap of using medical education as a fix-all solution for the health care system. It can absolutely play a part, but never at the expense of the true reason for medical education’s existence in the first place. Practically nobody argues against the fact that they physician’s role in this new era of health care will be as more of a “team captain” rather than an individual silo of knowledge who is the final authority on all things relating to medicine. If physicians are to occupy this role, they must have the deepest understanding of the reasons why patients present in the first place: for treatment of disease. Medical education that de-emphasizes scientific understanding in the name of awareness of topics that are not going to change unless the overriding incentives change produces physicians that are not all that different from our factory worker. Furthermore, in my opinion, sacrificing a solid understanding of disease and treatment deprives the physician of his/her most critical skill: the ability to truly understand what is causing the pathology of a presenting patient and develop effective/palliative treatments for that patient. Basic, unexciting, not eloquent…but this is the true reason why physicians exist in the first place. Physicians, just like any other professional group in society, are unable to collectively transcend the broader incentives that exist in their profession. Neither are the majority of medical students, by the way…as I discovered in my second year. Bill Clinton had the slogan “The economy, stupid” hanging in his campaign headquarters to constantly remind him of the most important issue in the 1992 presidential election. Maybe it is time for all people in decision making capacities to hang “The incentives, stupid” sign above their desks so that these circuitous “solutions” that seem appealing on the surface can be abandoned and true change can finally be realized.

EE Smith

You should think about submitting a guest post here.

morebuzzkills

I’ve always wanted to…but I’m afraid I might be a little too long winded for the 500 word length! If only they could fit some word control into my medical education! Oh wait…

EE Smith

http://twitter.com/drcarolw Carol Wilkinson

Brian, I agree that education surrounding health care costs and how clinical decisions impact cost is an integral part of medical education, however I don’t know if medical school is really the appropriate time to dive deep into the complexities of cost-effective care. Medical school is a time to learn and nail down the basics – the basic pathophysiology, basic understanding of lab tests, basic understanding of common procedures, how to do a history and physical exam. Before being able to make appropriate decisions on clinical management, let alone making decisions on clinical management in the contexts of cost-effective care, you have to learn how to develop a differential diagnosis and what management options are available to choose from.

That being said, academic medical centers could do a better job at educating all providers of cost-effective care. At UCSF, the internal medicine residents have a curriculum that involves analysis of real cases – looking at the clinical decisions, what other work up/management (based off of practice guidelines) options could have been made and the differences in cost. These types of discussions would be worth while on a Grand Rounds level, allowing multiple levels of providers (including 1st year medical students) to attend.

meyati

Somewhere in this- the patients Bill of Rights is lost. I have a doctor that’s concerned about financial cost-He changed after he poisoned me with statin-black urine- convulsions spasms- I managed to come out of most of it, but I still can’t hardly walk. He’s been very good in helping me-some doctors won’t-I’m the one that finally said -Yes- My cholesterol was in range-but I should think of what would happen to my disabled vet son if I had a stroke? You know what I did last month—I sent him a sample of my daily diet for radiation-3 eggs a day, whole milk, milk shakes, custards, puddings, -Then I asked him why I took statin. It also caused nasal drainage- which I didn’t have before-so the oncologists are concerned about the cancer dripping into my lungs-this type does. In about 8 months, we’ll know.

John Henry

Cost-containment is not really an appropriate subject for medical students. That is a matter that is more usefully left to residency where daily interaction with staff and trainee can take costs into consideration during management discussions on the wards and in clinic. Medical schools need to be left alone to teach medicine, not social work and public policy.

Guest

Doctors feel like they have the right to lie to patients, they do it all the time. Don’t wonder, when the truth about scams such as this one get out, that you’re seen as lying bullies who lie.